Description

Salary Range:$24.81/hour - $34.74

Job Summary

Expectations of this position is to provide robust customer service for CenCal Health’s membership and its provider network that is aligned with the Plan’s strategic goals and mission statement. In this role, the Member Services Representative (MSR) assists Plan members within all programs who may have difficulty navigating, understanding, and utilizing their healthcare benefits; who may have multiple and complex needs, limited communication skills, and may be transitioning between levels of care and types of service. The MSR also assists in the case management of Health Service Utilization, Care Management, Radiology Benefit Manager, Transportation coordination, and the Pharmacy Department, by being the Plan’s point of contact for the member and provider/pharmacies in the facilitation and coordination of services with the appropriate provider.

Duties and Responsibilities

CenCal Health’s MSR must embrace CenCal Health’s mission and to provide service to CenCal Health’s Medi-Cal membership which consists of the underserved and vulnerable populations such as the aged, blind, disabled, Foster Care Children, Medi-Care - Medi-Cal and Long-Term Care.

• Provide customer service in a queue environment within established service levels to all CenCal Health members, advocating on their behalf in assisting with Primary Care Physician selection, obtaining appointments, transportation and interpreter services, coordination of care, referrals to County Mental Health agencies, pharmacy issues, complete documentation of complaints/appeals while providing education of program benefits;

• Respond to members’ concerns that include complaints and appeals; identify and assess concurrent care issues, initiate appropriate action required for the immediate resolution including forwarding to department designee for coordination with Health Services; documentation of complaint/ appeal and forward to the grievance unit for investigation and resolution;

• Assist the Plan’s Provider Network with eligibility, status of referrals, authorizations, claims, and pharmacy medication status inquiries; and must demonstrate a thorough understanding of the relationship between the various health program agencies, Department of Social Services (DSS), Social Security Administration (SSA), Public Authority, Tri-Counties Regional Centers, Public Health Department, California Children’s Services, and their relationship to CenCal Health’s various healthcare program membership.

• Establish and maintain effective and cooperative working relations with internal health plan staff, and outside collaborative agencies such as DSS, Public Health Department, Tri-Counties Regional Centers, California Children’s Services, Public Authority, Alcohol Drug and Mental Health for SB County and Mental Health Services for SLO County, Social Security Administration and network providers;

• Identifying, triaging, and transitioning continuity of care issues; selection of Primary Care Providers (PCP); explaining program/benefits and making referrals to other programs, Community-Based Organizations, and services, as appropriate;

• Assisting members with authorizations, assist with the coordination of health care services between the Plan, network providers (all), RBM, Specialty Pharmacy, DME, and tertiary care facilities such as UCLA and other centers of excellence to ensure continuity of care for member;

• Assist with resolving issues relating to other health coverage, including researching and documenting changes to other health coverage and notifying Recoveries and DSS as appropriate.

• Assist members with member portal guidance and questions; including providing information on what the portal provides, and general account guidance.

• Assist the Call Center management team in responding and assisting members with their web inquiries.

• Must be able to maneuver and understand the following screens:

• Other duties as assigned

Qualifications

Knowledge/Skills/Abilities

• Proven excellent customer service experience and orientation skills

• Strong oral and written communication and interpersonal/relationship-building skills

• Excellent attention to detail

• Knowledge of CenCal Health and the Medi-Cal program is strongly preferred

• Demonstrate good judgment in making decisions within the scope of the position; ability to work independently with minimal supervision

• Able to multi-task in a fast-paced environment

• Strong problem-solving skills

• Proficiency in Word and Office Suite

• Good organizational skills

Education & Experience

Required:

• Experience working in a healthcare, human services, or public assistance environment in an administrative capacity, directly supporting the population utilizing medi-cal services (e.g., medical receptionist, regional center coordinator, patient advocacy, or related roles).

Preferred:

• Bilingual in Spanish